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Osaki Y, Maeoka Y, Sami M, Takahashi A, Ishiuchi N, Sasaki K, Masaki T. Peritoneal dialysis-associated peritonitis, caused by superior mesenteric artery thrombosis with intestinal necrosis: a case report. CEN Case Rep 2024:10.1007/s13730-024-00894-y. [PMID: 38825653 DOI: 10.1007/s13730-024-00894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/14/2024] [Indexed: 06/04/2024] Open
Abstract
Peritoneal dialysis (PD)-associated peritonitis is a common complication of PD. Enteric peritonitis is defined as peritonitis arising from an intestinal or intra-abdominal organ source. The delay in the diagnosis or treatment of enteric peritonitis has been reported to increase mortality. Therefore, the early consideration of enteric peritonitis, particularly in cases of culture-negative peritonitis, is imperative. A 67-year-old Japanese man who had been undergoing PD for 3 years, was admitted to our hospital with a diagnosis of PD-associated peritonitis. A month previously, he experienced a bleeding gastric ulcer, which led to severe anemia (hemoglobin 6.3 mg/dL), followed by thrombocytosis. On admission, peritoneal fluid analysis showed a high white blood cell count (WBC: 8,570 /µL), with neutrophils predominating (74.5%). Cultures of both his dialysis effluent and blood were negative. After admission, the WBC count of the dialysis effluent gradually decreased alongside antibiotic therapy, but the patient's abdominal pain did not improve. After 4 days, enhanced computed tomography showed superior mesenteric artery (SMA) thrombosis and intestinal necrosis. Therefore, emergency intestinal resection and PD catheter removal were performed, and then antithrombosis therapy was initiated. Because the patient's abdominal pain was improved and platelet count and D-dimer concentration were reduced by these treatments, he was discharged from the hospital after 47 days. Thus, we report a rare case of culture-negative PD-associated peritonitis, which was caused by SMA thrombosis and intestinal necrosis. It is likely that combination of severe calcification of SMA and prolonged thrombocytosis secondary to the severe anemia contributed to the thrombosis.
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Affiliation(s)
- Yosuke Osaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Yujiro Maeoka
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Mai Sami
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Akira Takahashi
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Naoki Ishiuchi
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Kensuke Sasaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan.
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2
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Duivenvoorden AAM, Metz FM, Wijenbergh R, Verberght HCR, van Bijnen AAJHM, Olde Damink SWM, Geelkerken RH, Lenaerts K, Lubbers T. Intestinal Fatty Acid Binding Protein as a Predictor of Early Mesenteric Injury Preceding Clinical Presentation: A Case Report. EJVES Vasc Forum 2024; 61:136-140. [PMID: 38884076 PMCID: PMC11176664 DOI: 10.1016/j.ejvsvf.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 04/01/2024] [Accepted: 04/23/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Diagnosing non-occlusive mesenteric ischaemia (NOMI) in patients is complicated, due to poor signs and symptoms and non-specific laboratory tests, leading to a high mortality rate. This case study presents the rare case of a patient who developed mesenteric ischaemia after an emergency thoracic endovascular aneurysm repair (TEVAR) for a type B aortic dissection (TBAD) and peri-operative cardiogenic shock. Study outcomes revealed that intestinal fatty acid binding protein (I-FABP) identified early mucosal damage two days before the clinical presentation. Report A 43 year old male patient was admitted to the emergency department with an acute TBAD and a dissection of the superior mesenteric artery (SMA), for which TEVAR was performed with additional stent placement in the SMA. Peri-operatively, the patient went into cardiogenic shock with a sustained period of hypotension. Post-operatively, the plasma I-FABP levels were measured prospectively, revealing an initial increase on post-operative day five (551.1 pg/mL), which continued beyond day six (610.3 pg/mL). On post-operative day seven, the patient developed a fever and demonstrated signs of peritonitis and bowel perforation. He underwent an emergency laparotomy, followed by an ileocaecal resection (<100 cm) with a transverse ileostomy. Pathological analysis confirmed the diagnosis of mesenteric ischaemia. Discussion The diagnosis of NOMI in critically ill patients is often complicated, and the currently available diagnostic markers lack the specificity and sensitivity to detect early intestinal injury. This case report highlights that elevated I-FABP in plasma levels may indicate the presence of early mesenteric injury. Further research needs to be conducted before I-FABP can be applied in daily practice.
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Affiliation(s)
- Annet A M Duivenvoorden
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
| | - Robin Wijenbergh
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Hanne C R Verberght
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Annemarie A J H M van Bijnen
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
| | - Kaatje Lenaerts
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
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3
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Are Mortality and Morbidity Predictable in Acute Mesenteric Ischemia? The Importance of Serum Lactate, Lactate Dehydrogenase, and Blood Urea Nitrogen Levels. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03719-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
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4
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Cirillo-Penn NC, DeMartino RR, Rasmussen TE, Shuja F, Colglazier JJ, Kalra M, Oderich GS, Mendes BC. Midterm Clinical Outcomes of Retrograde Open Mesenteric Stenting for Mesenteric Ischemia. Ann Vasc Surg 2023; 89:20-27. [PMID: 36404451 DOI: 10.1016/j.avsg.2022.09.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/03/2022] [Accepted: 09/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Retrograde open mesenteric stenting (ROMS) has become a mainstay in treatment of mesenteric ischemia; however, follow-up in contemporary studies is limited. METHODS A single-center retrospective review of patients undergoing ROMS from 2007 to 2020 was conducted. Demographics, presentation, and procedural details were reviewed. End points were morbidity and mortality, technical success, primary patency, reinterventions, and freedom from clinical recurrence. RESULTS ROMS was performed in 34 patients, 19 female (56%). Mean age was 71 ± 10 years. Eighteen patients (53%) presented with acute mesenteric ischemia (AMI), 11 (32%) with acute-on-chronic, and 5 (15%) with chronic mesenteric ischemia. Etiology was chronic atherosclerosis with/without in-situ thrombosis in 28 patients (82%), superior mesenteric artery dissection in 3, and 1 each with embolic, vasculitic, and nonocclusive ischemia. Four patients (12%) had prior mesenteric procedures (3 Celiac/1 superior mesenteric artery stent) and 1 had unsuccessful transbrachial stenting attempt. Technical success, defined as successful stenting through a retrograde approach was attained in 31 patients (91%), with the 3 remaining patients treated with transbrachial stenting in 2 and iliomesenteric bypass in 1. Covered stents were used in 21 patients (64%) with or without stent extension with bare-metal stents. Eight patients (23%) required thromboembolectomy and 9 (26%) underwent patch angioplasty. Thirty-day mortality rate was 35%, all in patients with AMI (10) or acute-on-chronic (2). Eighteen patients (53%) underwent bowel resection, all presenting acutely. Early reinterventions within the first 30 days were required in 5 patients (15%), including 2 redo ROMS with thrombectomy and endarterectomy, 2 percutaneous stent extensions, and 1 aortic septum fenestration with coiling of a jejunal branch pseudoaneurysm. With a median follow-up of 3.7 (interquartile range: 0.8-5.0) years, in patients surviving discharge, 5 required reintervention yielding freedom from reintervention rates of 87% at 1 year and 71% at 3 years. All postdischarge reinterventions were endovascular with no conversion to bypass. The overall 1-year and 3-year primary patency rates were 70% and 61% (primary-assisted patency at 1 and 3 years was 87% and secondary patency at 1 and 3 years was 97%). The freedom from symptom recurrence was 95% at 1 and 3 years. CONCLUSIONS ROMS carries high rates of technical success in patients with mesenteric ischemia, despite a high chronic atherosclerotic burden. Although mid-term patency rates are acceptable, AMI is still associated with high early morbidity and mortality, with high rates of associated bowel resection. ROMS is a valuable tool in the armamentarium of vascular surgeons.
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Affiliation(s)
| | | | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F, Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Biffl WL, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni MA, Koike K, Velmahos GC, Fraga GP, Fette A, de'Angelis N, Balogh ZJ, Scalea TM, Sganga G, Kelly MD, Khan J, Stahel PF, Moore EE. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022; 17:54. [PMID: 36261857 PMCID: PMC9580452 DOI: 10.1186/s13017-022-00443-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 02/08/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.
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Affiliation(s)
- Miklosh Bala
- Director of Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, POB 12000, 91120, Jerusalem, Israel.
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Jeffry Kashuk
- Tel Aviv Sackler School of Medicine, Tel Aviv, Israel
| | - Belinda De Simone
- Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Marco Ceresoli
- Emergency and General Surgery Department, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | | | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche region, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chirika Mircea
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, S.Maria Hospital Trust, Terni, Italy
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald V Maier
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kjetil Soreide
- HPB Unit, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Mark A Malangoni
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, PA, USA
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Nicola de'Angelis
- Unit of Digestive and HPB Surgery, Faculty of Medicine, University of Paris, Paris, France
| | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
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6
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Liau SK, Kuo G, Chen CY, Lu YA, Lin YJ, Lee CC, Hung CC, Tian YC, Hsu HH. Identifying survival protective factors for chronic dialysis patients with surgically confirmed acute mesenteric ischemia. World J Gastrointest Surg 2022; 14:809-820. [PMID: 36157361 PMCID: PMC9453328 DOI: 10.4240/wjgs.v14.i8.809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/02/2022] [Accepted: 07/22/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Mesenteric ischemia is significantly more common in end-stage kidney disease patients undergoing chronic dialysis than in the general population and is associated with high morbidity and mortality. However, reports on prognostic factors in this population are limited.
AIM To elucidate the in-hospital outcomes of acute mesenteric ischemia in chronic dialysis patients and to analyze protective factors for survival.
METHODS The case data of 426 chronic dialysis patients who were hospitalized in a tertiary medical center for acute mesenteric ischemia over a 14-year period were retrospectively reviewed. Of these cases, 103 were surgically confirmed, and the patients were enrolled in this study. A Cox regression analysis was used to evaluate the protective factors for survival.
RESULTS The in-hospital mortality rate among the 103 enrolled patients was 46.6%. Univariate analysis was performed to compare factors in survivors and nonsurvivors, with better in-hospital outcomes associated with a surgery delay (defined as the time from onset of signs and symptoms to operation) < 4.5 d, no shock, a higher potassium level on day 1 of hospitalization, no resection of the colon, and a total bowel resection length < 110 cm. After 1 wk of hospitalization, patients with lower white blood cell count and neutrophil counts, higher lymphocyte counts, and lower C-reactive protein levels had better in-hospital outcomes. Following multivariate adjustment, a higher potassium level on day 1 of hospitalization (HR 1.71, 95%CI 1.19 to 2.46; P = 0.004), a lower neutrophil count (HR 0.91, 95%CI 0.84 to 0.99; P = 0.037) at 1 wk after admission, resection not involving the colon (HR 2.70, 95%CI 1.05 to 7.14; P = 0.039), and a total bowel resection length < 110 cm (HR 4.55, 95%CI 1.43 to 14.29; P = 0.010) were significantly associated with survival.
CONCLUSION A surgery delay < 4.5 d, no shock, no resection of the colon, and a total bowel resection length < 110 cm predicted better outcomes in chronic dialysis patients with acute mesenteric ischemia.
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Affiliation(s)
- Shuh-Kuan Liau
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - George Kuo
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chao-Yu Chen
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yueh-An Lu
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yu-Jr Lin
- Research Services Center for Health Information, Chang Gung University, Taoyuan 333, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Cheng-Chieh Hung
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Ya-Chung Tian
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Hsiang-Hao Hsu
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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7
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Sumbal R, Ali Baig MM, Sumbal A. Predictors of Mortality in Acute Mesenteric Ischemia: A Systematic Review and Meta-Analysis. J Surg Res 2022; 275:72-86. [DOI: 10.1016/j.jss.2022.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/24/2021] [Accepted: 01/27/2022] [Indexed: 12/12/2022]
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8
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Otto CC, Czigany Z, Heise D, Bruners P, Kotelis D, Lang SA, Ulmer TF, Neumann UP, Klink C, Bednarsch J. Prognostic Factors for Mortality in Acute Mesenteric Ischemia. J Clin Med 2022; 11:jcm11133619. [PMID: 35806904 PMCID: PMC9267588 DOI: 10.3390/jcm11133619] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/07/2022] [Accepted: 06/20/2022] [Indexed: 12/23/2022] Open
Abstract
Postoperative mortality in patients undergoing surgical and/or interventional treatment for acute mesenteric ischemia (AMI) has remained an unsolved problem in recent decades. Here, we investigated clinical predictors of postoperative mortality in a large European cohort of patients undergoing treatment for AMI. In total, 179 patients who underwent surgical and/or interventional treatment for AMI between 2009 and 2021 at our institution were included in this analysis. Associations between postoperative mortality and various clinical variables were assessed using univariate and multivariable binary logistic regression analysis. Most of the patients were diagnosed with arterial ischemia (AI; n = 104), while venous ischemia (VI; n = 21) and non-occlusive mesenteric ischemia (NOMI; n = 54) were present in a subset of patients. Overall inhouse mortality was 55.9% (100/179). Multivariable analyses identified leukocytes (HR = 1.08; p = 0.008), lactate (HR = 1.25; p = 0.01), bilirubin (HR = 2.05; p = 0.045), creatinine (HR = 1.48; p = 0.039), etiology (AI, VI or NOMI; p = 0.038) and portomesenteric vein gas (PMVG; HR = 23.02; p = 0.012) as independent predictors of postoperative mortality. In a subanalysis excluding patients with fatal prognosis at the first surgical exploration (n = 24), leukocytes (HR = 1.09; p = 0.004), lactate (HR = 1.27; p = 0.003), etiology (AI, VI or NOMI; p = 0.006), PMVG (HR = 17.02; p = 0.018) and intraoperative FFP transfusion (HR = 4.4; p = 0.025) were determined as independent predictors of postoperative mortality. Further, the risk of fatal outcome changed disproportionally with increased preoperative lactate values. The clinical outcome of patients with AMI was determined using a combination of pre- and intraoperative clinical and radiological characteristics. Serum lactate appears to be of major clinical importance as the risk of fatal outcome increases significantly with higher lactate values.
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Affiliation(s)
- Carlos Constantin Otto
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany;
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany;
- Department of Vascular Surgery, University Hospital Bern, 3010 Bern, Switzerland
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Department of Surgery, Maastricht University Medical Center (MUMC), 6229 HX Maastricht, The Netherlands
| | - Christian Klink
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Department of Surgery, Diakonissen-Stiftungs-Krankenhaus Speyer, 67346 Speyer, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Correspondence: ; Tel.: +49-241-80-89501
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9
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Ksouri A, Copin P, Bonvalet F, Bozi L, Cazals-Hatem D, Garzelli L, Panis Y, Weiss E, Castier Y, Bouhnik Y, Corcos O, Vilgrain V, Ronot M, Nuzzo A. Colonic involvement in acute mesenteric ischemia: prevalence, risk factors, and outcomes. Eur Radiol 2022; 32:2813-2823. [PMID: 34657969 DOI: 10.1007/s00330-021-08318-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/30/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to investigate the prevalence, risk factors, and outcomes of colonic involvement in patients with acute mesenteric ischemia (AMI). METHODS CT scans from a prospective cohort of 114 AMI patients treated in an intestinal stroke center between 2009 and 2018 were blindly reviewed by two radiologists. Colon involvement was defined on CT scan by the presence of at least one of the following CT colonic features: wall thickening, pneumatosis, decreased wall enhancement, dilatation, or perforation. In addition, the clinical, biological, and radiological characteristics of patients with and without colonic involvement were compared to identify risk factors for colonic involvement on CT and its impact on morbidity and mortality. RESULTS Colonic involvement was identified in 32/114 (28%) patients with AMI, the right colon being more frequently involved (n = 29/32, 91%). Wall thickening (n = 27/32) was the most common CT finding. Occlusion of the inferior mesenteric artery was the only statistically significant risk factor for colonic involvement (35% vs. 15%, p = 0.02). Patients with colonic involvement on CT vs. those without had more frequently transmural colonic necrosis (13% vs. 0%, p = 0.006), short bowel syndrome (16% vs. 4%, p = 0.04), need for long-term parenteral support (19% vs. 5%, p = 0.03), and death during follow-up (22% vs. 10%, p = 0.03). DISCUSSION In patients with AMI, colonic involvement is associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment. KEY POINTS • In a prospective cohort of acute mesenteric ischemia patients from an intestinal stroke center, 28% had an associated colonic involvement on CT. • Colonic involvement on CT most commonly affected the right colon, and the occlusion of the inferior mesenteric artery was the only risk factor. • Colonic involvement on CT was associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment.
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Affiliation(s)
- Aida Ksouri
- Department of Radiology, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
| | - Pauline Copin
- Department of Radiology, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
| | - Fanny Bonvalet
- Department of Radiology, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
| | - Lilian Bozi
- Department of Radiology, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
| | | | - Lorenzo Garzelli
- Department of Radiology, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
- Université de Paris, INSERM UMR 1148, Laboratory for Vascular Translational Science, 75018, Paris, France
| | - Emmanuel Weiss
- Université de Paris, INSERM UMR 1148, Laboratory for Vascular Translational Science, 75018, Paris, France
- Intensive Care Unit, Beaujon HospitalAPHP.Nord, 92110, Clichy, France
| | - Yves Castier
- Université de Paris, INSERM UMR 1148, Laboratory for Vascular Translational Science, 75018, Paris, France
- Department of Vascular Surgery, Bichat Hospital, APHP.Nord, 75018, Paris, France
| | - Yoram Bouhnik
- Université de Paris, INSERM UMR 1148, Laboratory for Vascular Translational Science, 75018, Paris, France
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
| | - Olivier Corcos
- Université de Paris, INSERM UMR 1148, Laboratory for Vascular Translational Science, 75018, Paris, France
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
| | - Valérie Vilgrain
- Department of Radiology, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
- UMR 1149, Université de Paris, INSERM, 75018, Paris, CRI, France
| | - Maxime Ronot
- Department of Radiology, Beaujon Hospital, APHP.Nord, 92110, Clichy, France.
- UMR 1149, Université de Paris, INSERM, 75018, Paris, CRI, France.
| | - Alexandre Nuzzo
- Université de Paris, INSERM UMR 1148, Laboratory for Vascular Translational Science, 75018, Paris, France
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, Beaujon Hospital, APHP.Nord, 92110, Clichy, France
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10
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Prognostic Factors in Non-occlusive mesenteric ischemia: A pragmatic pre-operative score for the prediction of 28-day mortality. Am J Surg 2022; 224:617-623. [DOI: 10.1016/j.amjsurg.2022.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/08/2022] [Accepted: 03/25/2022] [Indexed: 11/22/2022]
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11
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Huang H, Wang H, Long Z, Wang M, Ding J, Peng J. Factors influencing hospital stay duration for patients with mild ischemic colitis: a retrospective study. Eur J Med Res 2022; 27:36. [PMID: 35246255 PMCID: PMC8897856 DOI: 10.1186/s40001-022-00665-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 02/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background Ischemic colitis is the most prevalent ischemic injury of the gastrointestinal tract. The majority of patients with mild ischemic colitis usually achieve complete clinical recovery shortly. However, the predictors of longer hospital stay duration are unclear. This study aimed to evaluate the predictors of hospital stay duration for patients with mild ischemic colitis. Methods We retrospectively evaluated 100 patients with mild ischemic colitis between January 2010 and December 2020 at Xiangya Hospital (a tertiary care center). The clinical characteristics and therapeutic drugs of patients who were hospitalized for ≤ 8 days and ≥ 12 days were compared. Results Of the 100 patients included, 63 (63%) were hospitalized for ≤ 8 days and 37 (37%) were hospitalized for ≥ 12 days. Patients with cerebrovascular disease (29.7% vs. 11.1%, p = 0.019) and abdominal surgical history (29.7% vs. 7.9%, p = 0.004) were more likely to be hospitalized for ≥ 12 days than for ≤ 8 days. The d-dimer levels [0.78 (0.41–1.82) vs. 0.28 (0.16–0.73), p = 0.001] and positive fecal occult blood test results (86.5% vs. 60.3%, p = 0.006) were higher in patients who were hospitalized for ≥ 12 days than in those who were hospitalized for ≤ 8 days. Probiotic use was greater in patients hospitalized for ≤ 8 days (76.2% vs. 54.1%, p = 0.022). Multivariate analysis indicated that cerebrovascular disease (odds ratio [OR] = 4.585; 95% confidence interval [CI] 1.129–18.624; p = 0.033), abdominal surgical history (OR = 4.551; 95% CI 1.060–19.546; p = 0.042), higher d-dimer levels (OR = 1.928; 95% CI 1.024–3.632; p = 0.042), and higher positive fecal occult blood test results (OR = 7.211; 95% CI 1.929–26.953; p = 0.003) were associated with longer hospital stays. Conclusion Cerebrovascular disease, abdominal surgical history, higher d-dimer levels, and higher positive fecal occult blood test results are independent and significant factors that influence longer hospital stays for patients with mild ischemic colitis. Probiotics helped reduce hospital stay in these patients.
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Affiliation(s)
- Haosu Huang
- Department of Gastroenterology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Hanyue Wang
- Department of Gastroenterology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Zhenpu Long
- Department of Gastroenterology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Meng Wang
- Department of Gastroenterology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Junjie Ding
- Department of Gastroenterology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China
| | - Jie Peng
- Department of Gastroenterology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, 410008, Hunan, China.
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12
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Augène E, Lareyre F, Chikande J, Guidi L, Mutambayi G, Lê CD, Jean-Baptiste E, Katsiki N, Mikhailidis DP, Raffort J. Incidence of contrast-induced acute kidney injury in patients with acute mesenteric ischemia and identification of potential predictive factors. Vascular 2021; 30:1097-1106. [PMID: 34645315 DOI: 10.1177/17085381211050766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Contrast-enhanced computed tomography angiography (CTA) is commonly used to investigate acute abdominal conditions, but the risk of contrast-induced acute kidney injury (CI-AKI) has been poorly investigated in patients with acute mesenteric ischemia. The aim of the present study was to evaluate the incidence of CI-AKI in these patients and identify potential predictive factors. METHODS Patients admitted for acute mesenteric ischemia who had a diagnostic CTA with contrast medium and a follow-up of creatinine concentration were retrospectively included. RESULTS Among 53 patients included, 9 (16.9%) developed CI-AKI. The prevalence of chronic kidney disease did not differ significantly between those who developed CI-AKI and those who did not (33.3 vs 18.2%, p=.372). Plasma total bilirubin and conjugated bilirubin levels were significantly higher in patients who developed CI-AKI (17.5 vs 8.0 μmol/L, p=.013 and 8.0 vs 3.0 μmol/L, p=.031, respectively). The proportion of patients who had revascularization was similar between patients who developed CI-AKI and those who did not (11.1 vs 20.5%, p>.999). No significant difference was observed for 30-day mortality and all-cause mortality for a median follow-up of 168 days (22.2 vs 13.6%, p=.611; and 33.3 vs 61.4%, p=.153, respectively). CONCLUSION This study reports the incidence of CI-AKI in patients with acute mesenteric ischemia after diagnostic CTA with contrast medium. Plasma bilirubin levels were a predictive factor of CI-AKI in these patients. The administration of contrast media during revascularization was not associated with an increased risk of CI-AKI.
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Affiliation(s)
- Emmanuel Augène
- Department of Visceral Surgery, 37045University Hospital of Nice, France
| | - Fabien Lareyre
- Department of Vascular Surgery, 70607Hospital of Antibes Juan-les-Pins, France.,Université Côte d'Azur, 37045CHU, Inserm U1065, C3M, Nice, France
| | - Julien Chikande
- Department of Vascular Surgery, 37045University Hospital of Nice, France
| | - Lucas Guidi
- Department of Vascular Surgery, 37045University Hospital of Nice, France
| | | | - Cong Duy Lê
- Department of Vascular Surgery, 70607Hospital of Antibes Juan-les-Pins, France
| | - Elixène Jean-Baptiste
- Université Côte d'Azur, 37045CHU, Inserm U1065, C3M, Nice, France.,Department of Vascular Surgery, 37045University Hospital of Nice, France
| | - Niki Katsiki
- First Department of Internal Medicine, Diabetes Center, Division of Endocrinology and Metabolism, 571848AHEPA University Hospital, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Juliette Raffort
- Université Côte d'Azur, 37045CHU, Inserm U1065, C3M, Nice, France.,Clinical Chemistry Laboratory, 37045University Hospital of Nice, France
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13
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Triple “L” (Leukocytosis, Lactate, and LDH): Predictors of Mesenteric Ischemia. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02495-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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14
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Ozturk S, Unver M, Ozdemir M, Bozbıyık O, Turk Y, Firat O, Calıskan C. Prognostic factors in acute mesenteric ischemia and evaluation with multiple logistic regression analysis effecting morbidity and mortality. POLISH JOURNAL OF SURGERY 2021; 93:25-33. [PMID: 33729172 DOI: 10.5604/01.3001.0014.5824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<b>Background:</b> Acute mesenteric ischaemia (AMI) is a catastrophic abdominal emergency characterized by sudden critical interruption to the intestinal blood flow which commonly leads to bowel infarction and death. AMI still has a poor prognosis with an in-hospital mortality rate of 50-69 %. This high mortality rate is related to the delay in diagnosis which is often diffucult and overlooked. Early intervention is crucial and the potential for intestinal viability. <br><b>Methods:</b> The charts of 140 patients who were hospitalazed with AMI between May 1997 and August 2013 in Ege University Faculty of Medicine, department of general surgery were retrospectively reviewed. Demographical and clinical features of patients determining the best predictors which effect on morbidity and mortality were evaluated by Multiple Logistic Regression analysis by Enter method after adjustment for all possible confounding factors. <br><b>Results:</b> After Multiple LR analysis by Enter method after adjustment for all possible confounding factors affecting morbidity; shock, exploration and stay in hospital were statistically significant. Age, cardiac comorbidities, ASA scores, the time delay between onset of acute abdominal pain to surgery, the presence of acidosis and shock, the involved organs (small bowel and both), type of surgery and medical treatment and small bowel length under 100 cm were statistically significant on mortality. <br><b>Conclusion:</b> Risk factors related to mortality and morbidity have been poorly analyzed due to lack of prospective studies and smaller number of patients. Early diagnosis generally depends on clinical awareness and suspicion. Age and time of delay between onset of acute abdominal pain to surgery longer than 24 hours are the most important parameters that predict the mortality for patients presenting with shock and acidosis.
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Affiliation(s)
- Safak Ozturk
- Izmir Economy University Medical Park Izmir Hospital,Department of General Surgery, Izmir, Turkey
| | - Mutlu Unver
- Izmir Economy University Medical Park Izmir Hospital,Department of General Surgery, Izmir, Turkey
| | - Murat Ozdemir
- Ege University Faculty of Medicine, Department of General Surgery, Izmir, Turkey
| | - Osman Bozbıyık
- Ege University Faculty of Medicine, Department of General Surgery, Izmir, Turkey
| | - Yigit Turk
- Ege University Faculty of Medicine, Department of General Surgery, Izmir, Turkey
| | - Ozgur Firat
- Ege University Faculty of Medicine, Department of General Surgery, Izmir, Turkey
| | - Cemil Calıskan
- Ege University Faculty of Medicine, Department of General Surgery, Izmir, Turkey
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15
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Seike T, Suda T, Oishi N. Conservative treatment of hepatic portal venous gas resulting from non-occlusive mesenteric ischemia: a case report. Clin J Gastroenterol 2021; 14:1404-1410. [PMID: 34173209 DOI: 10.1007/s12328-021-01468-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
A 73-year-old man with severe intellectual disability, malnutrition, and hypoalbuminemia presented to our hospital after experiencing vomiting following dinner. Electrocardiography revealed a sinus rhythm. Plain abdominal radiography showed branching radiolucency in the liver. Abdominal computed tomography (CT) revealed branching gaseous foci of low density in the portal vein and its tributaries, suggesting the presence of hepatic portal venous gas (HPVG). Abdominal contrast-enhanced CT showed a segmental lack of contrast enhancement in the intestinal wall despite the absence of vascular occlusion in the main trunk and branches of the mesenteric artery. The patient was diagnosed with non-occlusive mesenteric ischemia (NOMI) accompanied by HPVG. Peripheral parenteral nutrition, antibiotic treatment, and human serum albumin were administered. The HPVG disappeared approximately 20 h after hospitalization. Intravascular dehydration associated with hypoalbuminemia was considered to be the cause of NOMI; the latter improved through the early correction of dehydration and hypoalbuminemia. The presence of HPVG is usually considered a diagnostic clue in patients with abdominal catastrophe and is associated with high mortality. However, the current case demonstrates the pitfalls of assessing the severity of the underlying condition based solely on the presence of HPVG.
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Affiliation(s)
- Takuya Seike
- Department of Gastroenterology, Kanazawa Municipal Hospital, 3-7-3, Heiwa-machi, Kanazawa, Ishikawa, 921-8105, Japan.
- Department of Gastroenterology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Tusyoshi Suda
- Department of Gastroenterology, Kanazawa Municipal Hospital, 3-7-3, Heiwa-machi, Kanazawa, Ishikawa, 921-8105, Japan
| | - Naoki Oishi
- Department of Gastroenterology, Kanazawa Municipal Hospital, 3-7-3, Heiwa-machi, Kanazawa, Ishikawa, 921-8105, Japan
- Department of Gastroenterology, Graduate School of Medicine, Kanazawa University, Kanazawa, Ishikawa, 920-8641, Japan
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16
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Early Surgical Intervention Improves Survival in Acute Intestinal Ischemia in the Intensive Care Unit. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6672591. [PMID: 34055998 PMCID: PMC8147527 DOI: 10.1155/2021/6672591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/10/2021] [Indexed: 11/18/2022]
Abstract
The study is aimed at assessing whether the early surgical intervention improves survival in acute mesenteric ischemia with septic shock. A retrospective study design was applied to review the charts of patients admitted to the intensive care unit. The data were collected through a review of the full patient chart including physician and nursing notes, pathology reports, intraoperative findings, CT findings, and endoscopy. The diagnosis of AMI for each patient was determined through clinical presentation/endoscopic visualization/laboratory results/radiographic imaging, surgical exam (tissue or visual) and/or autopsy. Death and survival were evaluated between short and long-time-interval for septic shock groups using the chi-square test followed by calculating the P value. Total survival among the surgery group was 60 patients (95.24%) compared to 3 (4.76%) survival among patients who did not have surgery. The time from the onset of a shock to the time of surgical incision was calculated. The mean time to surgery was 17.7 hours. Total 65 patients (29.52%) had surgery between 4 and 12 hours from the onset of hypotension. Survivals among this group of patients were 41.7% (n = 25). The survival difference was statistically significant than died patients with respect to the time of surgical intervention (P = <0.001). Early removal of ischemic bowel in patients with AII-related surgery has improved survival.
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17
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Parys S, Daneshmand A, Sieunarine K, Watanabe Y. The effect of comorbidity on early clinical decision making in acute mesenteric ischemia. Acta Chir Belg 2021; 122:341-345. [PMID: 33870863 DOI: 10.1080/00015458.2021.1916281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Acute mesenteric ischemia (AMI) is a surgical emergency with a high mortality and morbidity rate. Prompt diagnosis and early surgical management are the cornerstones of management. In certain patients, however, treatment is futile and early palliative care, lessens patient, and family distress. The aim of this study was to investigate factors, focusing on patient comorbidity, that may predict futility of treatment and hence, guide clinicians in their decision making. PATIENTS AND METHODS Consecutive adult patients with AMI diagnosed on imaging were reviewed for demographics, comorbidity, imaging, and biochemical results. RESULTS Seventy patients were identified with average age of 67 (range 33 - 94). Overall hospital mortality was 72%. Patients were divided into three distinct groups, patients who recovered (27%), patients deceased despite surgical treatment (18%), and patients palliated on presentation (54%). Age was comparable between groups (61 vs. 69 vs. 69; p=.2). Length of stay was highest in the recovered group (41.6 vs. 12.3 vs. 2.8 d). Biochemically, only lactate level differed (3.1 vs. 2.3 vs. 5.3 mmol/L, p=.03). Both deceased and palliative group scored similarly but significantly higher than the recovered group in both the Charlson comorbidity index (CCI) (4.2 and 5.6 vs. 3.4, p=.02) and age-adjusted CCI (ACCI) (6.7 and 8.2 vs. 5; p<.01). Other co-morbidities of atrial fibrillation (AF) and hypertension were comparable. CONCLUSIONS Raised ACCI confers poor outcomes in AMI despite surgical management. ACCI may be used to aid early decision making in AMI, predicting futility of treatment, and altering management goals to palliative comfort care.
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Affiliation(s)
- Simon Parys
- General Surgery Department, Royal Perth Hospital, Perth, Australia
| | - Ali Daneshmand
- General Surgery Department, Royal Perth Hospital, Perth, Australia
| | | | - Yuki Watanabe
- General Surgery Department, Royal Perth Hospital, Perth, Australia
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18
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Crawford JD, Scali ST, Khan T, Back MR, Cooper M, Arnaoutakis DK, Berceli SA, Upchurch GJ, Huber TS, Giles KA. Effect of ischemia-reperfusion on outcomes after open mesenteric bypass for chronic mesenteric ischemia. J Vasc Surg 2021; 74:1301-1308.e1. [PMID: 33887424 DOI: 10.1016/j.jvs.2021.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Significant physiologic perturbations can occur in patients with chronic mesenteric ischemia (CMI) undergoing open mesenteric bypass (OMB). These events have frequently been attributed to ischemia-reperfusion events and have been directly implicated in the occurrence of multiple organ dysfunction (MOD). Scoring systems (MOD score [MODS] and sequential organ failure assessment [SOFA]) have been derived within the critical care field to provide a composite metric for these pathophysiologic changes. The purpose of the present study was to describe the early pathophysiologic changes that occur after OMB for CMI and determine whether these are predictive of the outcomes. METHODS Patients with CMI who had undergone elective OMB from 2002 to 2018 at a single institution were reviewed. Changes in the hemodynamic, pulmonary, hepatic, renal, and hematologic parameters in the first 96 hours postoperatively were analyzed. The MODSs and SOFA scores were calculated. Cox regression was used to determine the association of the MODSs and SOFA scores with the outcomes. RESULTS The use of OMB was analyzed for 72 patients (age, 66 ± 11 years; 68% women; body mass index, 23.8 ± 6 kg/m2; 48 ± 34-lb weight loss in 59%). Previous mesenteric stent placement or bypass had been performed in 39% [stenting in 21; bypass in 8; (one patient had both)]. An antegrade configuration (93%) was most common (retrograde configuration, 7%), with revascularization of the superior mesenteric artery/celiac vessels in 85% (superior mesenteric artery only in 15%). Postoperative pathophysiologic and metabolic changes were common, and the mean MODSs and SOFA scores were 3.6 ± 2.4 (range, 1-10) and 4.0 ± 2.7 (range, 1-13), respectively. The median length of stay was 14 days (interquartile range, 9-21). The 30-day mortality was 4% (n = 3) and in-hospital morbidity was 53% (n = 38; gastrointestinal, 25%; infectious, 22%; cardiac, 18%; pulmonary, 18%; renal, 11%). The clinical follow-up period was 16 ± 20 months. The MODSs and SOFA scores correlated linearly with overall mortality (MODS: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; P < .01; SOFA score: OR, 1.4; 95% CI, 1.2-1.7; P < .01 per unit), with a score of ≥5 the inflection point most predictive of mortality (MODS: OR, 3.9; 95% CI, 1.6-9.9; P ≤ .01; SOFA score: OR, 2.8; 95% CI, 1.2-6.6; P = .02). The 1- and 3-year primary bypass patency and freedom from reintervention was 91% ± 5% and 83% ± 7%, respectively, with no association with the MODSs or SOFA scores. The 1- and 3-year survival was 86% ± 4% and 71% ± 6% with significantly worse outcomes for patients with higher MODSs and/or SOFA scores. CONCLUSIONS Most CMI patients undergoing OMB will experience significant metabolic derangements resulting from sequelae of the ischemia-reperfusion phenomenon postoperatively. These can be objectively assessed in the early postoperative period using simply applied scoring systems to reliably predict the early and long-term outcomes. A derivation of the MODS and/or SOFA score after OMB for CMI can identify the most vulnerable patients at the greatest risk of mortality. (J Vasc Surg 2021;XX:XX-X.).
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Affiliation(s)
- Jeffrey D Crawford
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
| | - Tabassum Khan
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Michol Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Dean K Arnaoutakis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Gilbert J Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
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19
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Wu W, Zhou Z. A Comprehensive Way to Access Hospital Death Prediction Model for Acute Mesenteric Ischemia: A Combination of Traditional Statistics and Machine Learning. Int J Gen Med 2021; 14:591-602. [PMID: 33658832 PMCID: PMC7920592 DOI: 10.2147/ijgm.s300492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/04/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose This study aimed to use traditional statistics and machine learning to develop and validate prediction models for predicting hospital death in patients with AMI and compare these models' performance. Patients and Methods Data were retrieved from the Medical Information Mart for Intensive Care (MIMIC III) electronic clinical database. A total of 338 eligible AMI patients were divided into a training cohort (n = 238) and a validation cohort (n = 100), and all patients were divided into survival groups and nonsurvival groups according to patients' hospital outcomes. The performance of the traditional statistics prediction model and the optimal machine learning prediction model was evaluated and compared with respect to discrimination, calibration, and clinical utility in the validation cohort. Results Univariate and multivariate logistic regression analyses identified the following independent risk factors associated with hospital death for AMI in the training cohort, including diastolic blood pressure, blood lactate, blood creatinine, age, blood pH, and red blood cell distribution width. Both the nomogram (AUC = 77.0%, 67.9-86.1%) and optimal machine learning model (AUC = 82.9%, 74.9-91.0%) achieved good discrimination and calibration in the validation cohort. Decision curves analysis showed that the optimal machine learning model has a greater net benefit than that of nomogram in this study. Conclusion The nomogram achieved a concise and relatively accurate prediction of hospital death in patients with AMI, the machine learning model also has good discrimination and seems to have better clinical utility. Traditional statistics may help infer the relationship between risk factors and hospital death, while machine learning may contribute to a more accurate prediction. Traditional statistics and machine learning are complementary in developing the prediction model for hospital death of AMI. Therefore, a combination of nomogram-machine learning (Nomo-ML) predictive model may improve care and help clinicians make AMI management-related decisions.
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Affiliation(s)
- Wenhan Wu
- Institute of Digestive Surgery of Sichuan University, Chengdu, 610041, Sichuan.,Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan
| | - Zongguang Zhou
- Institute of Digestive Surgery of Sichuan University, Chengdu, 610041, Sichuan.,Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, 610041, Sichuan
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Mothes H, Wickel J, Sponholz C, Lehmann T, Kaluza M, Zanow J, Doenst T. Monitoring of the Progression of the Perioperative Serum Lactate Concentration Improves the Accuracy of the Prediction of Acute Mesenteric Ischemia Development After Cardiovascular Surgery. J Cardiothorac Vasc Anesth 2021; 35:1792-1799. [PMID: 33663981 DOI: 10.1053/j.jvca.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To examine the sensitivity and specificity of perioperative lactate gradients for the prediction of subsequent acute mesenteric ischemia development in patients undergoing cardiovascular surgery. DESIGN Retrospective, single-center, case-control study. SETTING University hospital. PARTICIPANTS The study comprised 108 (1.15%) patients with acute mesenteric ischemia who were selected from 9,385 patients who underwent cardiovascular surgery and were matched to 324 control patients by age and surgery type. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Univariate and logistic regression analyses were used to examine intraoperative and early postoperative lactate levels in patients with and without mesenteric ischemia after cardiac surgery. Late intraoperative lactate concentrations were significantly greater in patients who subsequently developed mesenteric ischemia (p < 0.001). Patients with lactate levels >3 mmol/L had a four-fold increased risk of mesenteric ischemia development (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.4-7.5; area under the curve [AUC] 0.597; p < 0.002). Patients whose lactate levels remained >3 mmol/L on the first postoperative day had a nearly eight-fold increased risk (OR 7.8, 95% CI 4.6-13.3; AUC 0.68; p < 0.001), indicating that mesenteric ischemia developed at an early stage in almost every second patient (p < 0.001). For patients with normal or less elevated lactate levels, similar results were obtained for a >200% increase between the intraoperative and early postoperative periods (OR 4.1, 95% CI 2.4-6.8; AUC 0.62; p < 0.001). CONCLUSION Late intraoperative and early postoperative lactate levels >3 mmol/L and increases >200%, even when remaining within the normal range, should raise the suspicion of subsequent mesenteric ischemia development.
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Affiliation(s)
- Henning Mothes
- Department of General, Visceral and Vascular Surgery, Sophien- und Hufeland-Klinikum, Weimar, Germany.
| | - Jana Wickel
- Department of Obstetrics and Gynecology, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christoph Sponholz
- Department of Anesthesia and Intensive Care, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Informatics and Documentation, University Hospital, Jena, Germany
| | - Mirko Kaluza
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Juergen Zanow
- Department of General, Visceral and Vascular Surgery, Sophien- und Hufeland-Klinikum, Weimar, Germany
| | - Torsten Doenst
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
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Grotelueschen R, Miller V, Heidelmann LM, Melling N, Ghadban T, Grupp K, Reeh M, Welte MN, Uzunoglu FG, Izbicki JR, Bachmann KA. Acute Mesenteric Infarction: The Chameleon of Acute Abdomen Evaluating the Quality of the Diagnostic Parameters in Acute Mesenteric Ischemia. Dig Surg 2021; 38:149-157. [PMID: 33503619 DOI: 10.1159/000512779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 10/25/2020] [Indexed: 12/10/2022]
Abstract
INTRODUCTION/OBJECTIVE Acute mesenteric ischemia (AMI) is difficult to diagnose. Since the established parameters have low sensitivity and specificity, the aim of this study is to analyze the diagnostic quality of the established parameters of AMI. METHODS All patients that underwent emergency surgery due to suspected diagnosis of mesenteric ischemia at the University Medical Center Hamburg-Eppendorf between 2008 and 2014 were evaluated. Overall, 275 patients were enrolled and pre-, intra- and postoperative data were evaluated. RESULTS In 200 patients, a mesenteric ischemia was confirmed intraoperatively, and 75 patients had no ischemia. Comparing these groups, the rate of patients with pH < 7.2 (25 vs. 12%; p = 0.021) and elevated mean CRP level (175 ± 117 mg/L vs. 139 ± 104 mg/L; p = 0.019) was significantly higher in ischemic patients. There was no significant difference in the level of preoperative lactate. Concerning abdominal CT scan, a sensitivity and specificity of 61 and 68%, respectively, was found. CONCLUSION New diagnostic parameters are needed. So far, explorative laparotomy is the only reliable diagnostic method to detect mesenteric infarction.
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Affiliation(s)
- Rainer Grotelueschen
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Verena Miller
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Lena M Heidelmann
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany,
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tarik Ghadban
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Grupp
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Maria-Noemi Welte
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Faik Güntac Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kai A Bachmann
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Then E, Lund C, Uhlenhopp DJ, Sunkara T, Gaduputi V. Cirrhosis Is Associated With Worse Outcomes in Ischemic Colitis: A Nationwide Retrospective Study. Gastroenterology Res 2020; 13:253-259. [PMID: 33447304 PMCID: PMC7781274 DOI: 10.14740/gr1339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/17/2020] [Indexed: 11/11/2022] Open
Abstract
Background Ischemic colitis (IC) occurs when the blood supply of the large intestine becomes compromised. Cirrhosis is a disease entity in which there is a delicate balance between pro-coagulant and anti-coagulant states. Our aim was to examine the impact cirrhosis has on outcomes in patients with ischemic colitis. Methods A retrospective analysis of patients hospitalized with IC in 2017 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital charge, rates of colectomy and in-hospital mortality were extracted from the database. Categorical variables were compared using the Chi-square test and continuous variables were compared using t-test. Results A total of 29,035 patients with IC were identified, while 420 of these patients also had cirrhosis. Patients with IC and cirrhosis were noted to be younger age at presentation when compared to patients with IC and no cirrhosis (mean 63.9 years vs. 70.4 years; P < 0.001). When comparing both groups, IC patients with cirrhosis were more likely to be male (50% vs. 26.1%; P < 0.001), Black (10.9% vs. 7.6%; P = 0.013) and Hispanic (18% vs. 6.1%; P < 0.001). We found that IC patients with cirrhosis had a longer LOS (7.3 days vs. 4.8 days; P < 0.001), higher total hospital charge ($84,769 vs. $48,347; P < 0.001) and higher mortality rate (10.7% vs. 3.6%; P < 0.001); however, the presence of cirrhosis was not associated with increased odds of undergoing colectomy (odds ratio: 0.31; 95% confidence interval: 0.07 - 1.27; P = 0.104). Conclusions The presence of cirrhosis is associated with increased odds of in-hospital mortality in those presenting with IC. This compounds the already high rates of mortality in patients that undergo surgery for IC and could reflect lack of reserve to withstand the ischemic episode in the setting of cirrhosis. Though odds of undergoing colectomy is not increased, patients with cirrhosis warrant closer observation.
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Affiliation(s)
- Eric Then
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center - Clinical Affiliate of The Mount Sinai Hospital, Brooklyn, NY, USA
| | - Caitlin Lund
- Department of General Surgery, MercyOne Des Moines Medical Center, Des Moines, IA, USA
| | - Dustin J Uhlenhopp
- Department of Internal Medicine, MercyOne Des Moines Medical Center, Des Moines, IA, USA
| | - Tagore Sunkara
- Department of Gastroenterology and Hepatology, MercyOne Des Moines Medical Center, Des Moines, IA, USA
| | - Vinaya Gaduputi
- Department of Gastroenterology and Hepatology, MercyOne Des Moines Medical Center, Des Moines, IA, USA
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Wu W, Yang L, Zhou Z. Clinical Features and Factors Affecting Postoperative Mortality for Obstructive Acute Mesenteric Ischemia in China: A Hospital- Based Survey. Vasc Health Risk Manag 2020; 16:479-487. [PMID: 33268989 PMCID: PMC7701155 DOI: 10.2147/vhrm.s261167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/09/2020] [Indexed: 02/05/2023] Open
Abstract
Purpose The study aimed to report the clinical manifestation and identify the risk factors for postoperative mortality in patients who were diagnosed with obstructive acute mesenteric ischemia (AMI) based on a survey of a hospital in western China. Patients and Methods We reviewed clinical data of 108 patients with obstructive AMI at West China Hospital, Sichuan University, from 2011 to 2017. Clinical characteristic was described and compared. Factors affecting postoperative survival were analyzed. Results A total of 108 obstructive AMI cases were included in this study, with an overall average age of 57.1 years, including 58 arterial occlusive mesenteric ischemia (AOMI) and 50 mesenteric venous thrombosis (MVT). AOMI patients were older and had a significantly higher frequency of these comorbidities, including heart disease, hypertension, and diabetes. In comparison, MVT had a significantly higher proportion of male patients and a higher frequency of liver disease. A total of 77 patients underwent laparotomy, and the 30-day postoperative mortality rate was 29.9%. Multivariate logistic regression analysis showed that the time interval from admission to surgery (adjust OR 1.19; 95% CI [1.07–1.34], P = 0.005), platelet count (adjust OR = 0.98; 95% CI [0.97–0.99], P = 0.008) and AOMI (adjust OR = 5.55; 95% CI [1.36–22.55], P = 0.017) were independent predictors of 30-day mortality after exploratory laparotomy for obstructive AMI. Further analysis of the 45 AOMI showed that the time interval from admission to surgery (adjustOR 1.22; 95% CI [1.01–1.47], P = 0.036) and platelet count (adjustOR = 0.98; 95% CI [0.97–0.99], P = 0.020) were independent risk factors for 30-day postoperative mortality of AOMI. Conclusion Early identification of AOMI, improving the efficiency of enhanced CT examination, strengthening doctor–patient communication, active laparotomy, and optimize platelet management may also help reduce the overall short-term mortality of obstructive AMI. Building the multidisciplinary team model of diagnostic imaging, vascular intervention, and surgical treatment to manage obstructive AMI may be urgently needed in western China.
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Affiliation(s)
- Wenhan Wu
- Institute of Digestive Surgery of Sichuan University and Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Lie Yang
- Institute of Digestive Surgery of Sichuan University and Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Zongguang Zhou
- Institute of Digestive Surgery of Sichuan University and Department of Gastrointestinal Surgery, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
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Acosta-Mérida MA, Marchena-Gómez J, Saavedra-Santana P, Silvestre-Rodríguez J, Artiles-Armas M, Callejón-Cara MM. Surgical Outcomes in Acute Mesenteric Ischemia: Has Anything Changed Over the Years? World J Surg 2020; 44:100-107. [PMID: 31531725 DOI: 10.1007/s00268-019-05183-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite increases in knowledge and advances in the management of acute mesenteric ischemia syndrome (AMI), there have been no significant improvements in mortality in recent years. The objective of this study was to assess the changes in clinical characteristics and surgical outcomes in patients who underwent AMI over time. METHODS A total of 323 consecutive patients who underwent acute mesenteric ischemia at our institution between 1990 and 2015 were examined. The occurrence of significant changes over this 25-year period in demographic data, comorbidity, clinical characteristics, laboratory results, operative findings, etiology of the AMI, and operative mortality were evaluated. The evolution mortality rates for the studied period were analyzed using the additive logistic regression, and the significant effect was determined using the Akaike Information Criterion (AIC). RESULTS A significant increasing linear trend was observed in recent years in Charlson score values (p = 0.008), antiplatelet drug intake (p < 0.001), use of CT scan (p < 0.001), arterial thrombosis (p < 0.001), and intestinal resection (p = 0.047), while a decreasing linear trend was observed in digoxin intake (p < 0.001), angiography use (p = 0.004), and embolia (p < 0.001). The rest of the parameters did not present changes over time. Regarding the evolution of the adjusted surgical mortality, a significant decrease according the AIC criterion was observed. CONCLUSIONS In recent years, the characteristics of patients with AMI requiring surgery have changed. Changes in operative mortality have also been detected, showing a tendency toward a progressive and significant decrease.
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Affiliation(s)
- María Asunción Acosta-Mérida
- Department of General and Digestive Surgery, Hospital Universitario de Gran Canaria "Dr. Negrín", University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, The Canary Islands, Spain
| | - Joaquín Marchena-Gómez
- Department of General Surgery, Hospital Universitario de Gran Canaria Dr. Negrín, Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain.
| | - Pedro Saavedra-Santana
- Departament of Mathematics, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, The Canary Islands, Spain
| | - José Silvestre-Rodríguez
- Department of General and Digestive Surgery, Hospital Universitario de Gran Canaria "Dr. Negrín", University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, The Canary Islands, Spain
| | - Manuel Artiles-Armas
- Department of General and Digestive Surgery, Hospital Universitario de Gran Canaria "Dr. Negrín", University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, The Canary Islands, Spain
| | - María Mar Callejón-Cara
- Department of General and Digestive Surgery, Hospital Universitario de Gran Canaria "Dr. Negrín", University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, The Canary Islands, Spain
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Preoperative Risk Factors for Short-Term Postoperative Mortality of Acute Mesenteric Ischemia after Laparotomy: A Systematic Review and Meta-Analysis. Emerg Med Int 2020; 2020:1382475. [PMID: 33083058 PMCID: PMC7556094 DOI: 10.1155/2020/1382475] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 02/05/2023] Open
Abstract
Objective Our objective was to comprehensively present the evidence of preoperative risk factors for short-term postoperative mortality of acute mesenteric ischemia after laparotomy. Methods PubMed, Embase, and Google Scholar were searched from January 2000 to January 2020. Studies evaluating the postoperative risk factors for short-term postoperative mortality of acute mesenteric ischemia after laparotomy were included. The outcome extracted were patients' demographics, medical history, and preoperative laboratory tests. Results Twenty studies (5011 patients) met the inclusion criteria. Studies were of high quality, with a median Newcastle-Ottawa Scale Score of 7. Summary short-term postoperative mortality was 44.38% (range, 18.80%–67.80%). Across included studies, 49 potential risk factors were examined, at least two studies. Meta-analysis of predictors based on more than three studies identified the following preoperative risk factors for higher short-term postoperative mortality risk: old age (odds ratio [OR], 1.90, 95% confidence interval [CI], 1.57–2.30), arterial occlusive mesenteric ischemia versus mesenteric venous thrombosis (OR, 2.45, 95% CI 1.12–5.33), heart failure (OR 1.33, 95% CI 1.03–1.72), renal disorders (OR 1.61, 95% CI 1.24–2.07), and peripheral vascular disease (OR 1.38, 95% CI 1.00–1.91). Nonsurvivors were older (standardized mean difference [SMD], 0.32, 95% CI 0.24–0.40), had higher creatinine levels (SMD 0.50, 95% CI 0.25–0.75), and had lower platelet counts (SMD −0.32, 95% CI −0.50 to −0.14). Conclusion The short-term postoperative mortality of acute mesenteric ischemia who underwent laparotomy is still high. A better understanding of these risk factors may help in the early identification of high-risk patients, optimization of surgical procedure, and improvement of perioperative management.
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Vascular Calcifications are Associated with Increased Mortality in Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2020; 72:88-97. [PMID: 32866577 DOI: 10.1016/j.avsg.2020.08.086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Vascular calcifications have been identified as predictors of mortality in several cardiovascular diseases but have not been investigated in context of acute mesenteric ischemia. The aim of this study was to investigate the impact of vascular calcifications in patients with acute mesenteric ischemia. METHODS Patients admitted for an acute mesenteric ischemia were retrospectively included. The presence of calcifications in the visceral aorta, the celiac trunk, the superior mesenteric artery, and the renal arteries was assessed on computed tomography scan images at the arterial phase. The calcification volumes were measured using the software Aquarius iNtuition Edition®. RESULTS The all-cause mortality was 55 out of 86 patients (63.9%) for a median follow-up of 3.5 days (1-243). The survival rate of patients with calcification in the superior mesenteric artery was significantly lower than that of those without calcification (22% vs. 55.6%, P = 0.019). Patients who died had significantly a higher frequency of calcifications in the superior mesenteric artery, the visceral aorta, the celiac trunk, and the renal arteries. CONCLUSIONS The presence of vascular calcifications in the superior mesenteric artery is associated with increased mortality in patients diagnosed with acute mesenteric ischemia. Further studies are required to identify the mechanisms underlying this association.
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Suzuki S, Kondo H, Furukawa A, Kawai K, Yukaya T, Shimazui T, Tani M, Yamamoto M. Prognostic Factors of Preoperative Examinations for Non-occlusive Mesenteric Ischemia: A Multicenter Retrospective Project Study Conducted by the Japanese Society for Abdominal Emergency Medicine. World J Surg 2020; 44:3687-3694. [DOI: 10.1007/s00268-020-05678-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Chen FF, Ye XN, Jiang HT, Zhu GX, Miao SL, Yu GF, Qiu YH, Huang JY. Role of Frailty and Comorbidity Status in Predicting Morbidity and Mortality in Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2020; 67:105-114. [PMID: 32240729 DOI: 10.1016/j.avsg.2020.03.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/21/2020] [Accepted: 03/14/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study was performed to determine the association of frailty and comorbidity status with postoperative morbidity and mortality in patients with acute mesenteric ischemia (AMI). METHODS Patients diagnosed with AMI between April 2006 and September 2019 were enrolled in this study. Frailty was evaluated by sarcopenia which was diagnosed by third lumbar vertebra psoas muscle area (PMA). Comorbidity status was evaluated by the Charlson Comorbidity Index (CCI) score. Univariate and multivariate analyses evaluating the risk factors for postoperative morbidity and mortality were performed. RESULTS Of the 174 patients, 86 were managed conservatively and 88 underwent surgery. In surgically managed patients, 39.8% developed complications within 30 days of surgery. Ten patients died within 30 days of the operation. In the univariate analyses, white blood cell >10 g/L, low PMA, CCI score ≥2, and bowel resection were associated with postoperative complications. Multivariate analysis revealed that low PMA, CCI score ≥2, and bowel resection were independent predictors of postoperative complications. CONCLUSIONS This study demonstrated that low PMA, CCI score ≥2, and bowel resection were independent risk factors for postoperative complications in patients with AMI. Preoperative assessment of frailty using PMA and the evaluation of comorbidity status using CCI may serve as helpful tools in preoperative risk assessment and should be integrated into scoring systems for surgically treated AMI.
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Affiliation(s)
- Fan-Feng Chen
- Department of Vascular Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Xiao-Ning Ye
- The First Clinical Medical College, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Hao-Te Jiang
- The First Clinical Medical College, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Guan-Xia Zhu
- Department of Oncology, The First Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Shou-Liang Miao
- Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Guan-Feng Yu
- Department of Vascular Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Yi-Hui Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
| | - Jing-Yong Huang
- Department of Vascular Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China.
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Evaluation of the Impact of Sarcopenia in Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2020; 63:170-178.e1. [DOI: 10.1016/j.avsg.2019.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/03/2019] [Accepted: 07/22/2019] [Indexed: 12/21/2022]
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Corrales D, Giraldo DA. Intestinal necrosis caused by acute mesenteric ischemia associated with pregnancy: A case report and literature review. Int J Surg Case Rep 2020; 74:164-167. [PMID: 32862108 PMCID: PMC7475227 DOI: 10.1016/j.ijscr.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/24/2020] [Accepted: 08/06/2020] [Indexed: 11/19/2022] Open
Abstract
Acute mesenteric ischemia associated with pregnancy is a rare pathology that is difficult to treat. Acute mesenteric ischemia can be caused by a venous thrombosis associated with gestation. Acute mesenteric ischemia should be considered in pregnant woman. Patient with intense intestinal necrosis, need a intestinal resection which would cause a short bowel syndrome.
Introduction Mesenteric ischaemia associated with pregnancy is a rare disease with a high mortality rate and its prognosis depends on the time passing between diagnosis and final management. Presentation of case A 38-year-old Peruvian woman developed intestinal necrosis during week 35 of her pregnancy because of mesenteric ischaemia associated with her pregnancy. Discussion Given the findings of extensive intestinal necrosis, surgical resection was performed, causing short bowel syndrome. Histopathological analysis confirmed that the immediate cause of the patient’s ischaemia was venous thrombosis associated with her gestation. Conclusion Acute mesenteric ischaemia should be considered as a possible diagnosis in pregnant woman with risk factors for thrombophilia presenting with abdominal pain.
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Affiliation(s)
- Dora Corrales
- Departamento Materno-infantil del Hospital III EsSalud - Chimbote, Peru.
| | - Daniel A Giraldo
- Universidad Peruana Cayetano Heredia, Facultad de Medicina - Lima, Peru; Sociedad Científica de Estudiantes de Medicina Cayetano Heredia - Lima, Peru.
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Vural V, Ozozan OV. The Usefulness of Inflammation-based Prognostic Scores for the Prediction of Postoperative Mortality in Patients Who Underwent Intestinal Resection for Acute Intestinal Ischemia. Cureus 2019; 11:e6372. [PMID: 31886096 PMCID: PMC6910613 DOI: 10.7759/cureus.6372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective The current study was conducted to clarify whether the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are clinically useful in predicting postoperative mortality among patients undergoing surgery for acute intestinal ischemia (AII). Materials and methods The study was conducted as a retrospective investigation of 37 consecutive patients operated for AII between January 2014 and September 2019. Data regarding potential prognostic factors, including age, sex, preoperative white blood cell count (WBC), C-reactive protein (CRP), neutrophil, lymphocyte, and platelet counts were obtained from medical records. Results Univariate analysis revealed that age, WBC, and neutrophil count were predictors of postoperative mortality. In multivariate analysis, age (OR =1.14; 95% CI, 1.005-1.303; P=0.02) was found to be the only independent variable predicting postoperative mortality. Conclusions Preoperative NLR and PLR cannot be used as independent variables to predict postoperative 30-day mortality in patients with AII who underwent surgery.
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Affiliation(s)
- Veli Vural
- General Surgery, Akdeniz University Hospital, Antalya, TUR
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Matthaei H, Klein A, Branchi V, Kalff JC, Koscielny A. Acute mesenteric ischemia (AMI): absence of renal insufficiency and performance of early bowel resection may indicate improved outcomes. Int J Colorectal Dis 2019; 34:1781-1790. [PMID: 31512020 DOI: 10.1007/s00384-019-03388-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Acute mesenteric ischemia (AMI) is still associated with very high morbidity and mortality while the rareness and heterogeneity hamper the establishment of evidence-based guidelines. We sought to help standardize contemporary treatment by a cohort study at our tertiary center in the rising endovascular age. METHODS A retrospective cohort study was conducted from 2005 to 2015. Patients with occlusive (OMI), non-occlusive (NOMI), and venous mesenteric ischemia (VMI) were compared with respect to clinical and treatment parameters as well as outcome. RESULTS The study cohort consisted of 48 patients composed of 27 males and 21 females with an average age of 63 years and an average BMI of 25.1 kg/m2. In 48% of patients (N=23), an acute arterial OMI had occurred while NOMI was present in 31% (N=15) and VMI in 21% (N=10). Interventional and intraoperative recanalizations were significantly more often required in OMI patients compared with other entities (p=0.003). Patients with venous mesenteric ischemia had a significant better overall survival than patients with OMI or NOMI in the univariate analysis (p=0.027). Patients with renal failure had a 14.7-fold higher relative risk (Cox p=0.013) and patients without bowel resection during primary surgery had a 17.8-fold higher relative risk (Cox p=0.047) to die of AMI in the postoperative course. CONCLUSIONS AMI remains a rare but oftentimes fatal disease. Our study provides evidence that outcome may depend on the AMI subtype, presence of renal insufficiency, and early bowel resection. Further research should help individualize treatment for optimized outcomes.
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Affiliation(s)
- Hanno Matthaei
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Alina Klein
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Vittorio Branchi
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Jörg C Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Arne Koscielny
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.
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Memet O, Zhang L, Shen J. Serological biomarkers for acute mesenteric ischemia. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:394. [PMID: 31555708 DOI: 10.21037/atm.2019.07.51] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute mesenteric ischemia (AMI) defines a complex of conditions characterized by an interruption of the splanchnic circulation, leading to insufficient oxygen delivery or utilization to fill the metabolic needs of the visceral organs. Early diagnosis and immediate therapy are the cornerstones of early ischemia to reach a successful outcome and are necessary to reduce the high mortality. Although there is still lack of specific biomarkers to assist the diagnosis of AMI in clinical practice, there are several biomarkers with high specificity, may become a potential tools in early diagnosis of AMI, including intestinal fatty acid binding protein (I-FABP), a-glutathione S-transferase (a-GST), D-dimer, L- and D-lactate, citrulline, ischemia modified albumin, procalcitonin (PCT). However, they use in clinical limited duo to the many studies about these makers finished with small patient populations, and heterogeneous among these populations. This review describes the etiology of AMI, the current most studied promising biomarkers, the current research situation and future of biomarker research.
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Affiliation(s)
- Obulkasim Memet
- Center of Emergency & Intensive Care Unit, Medical Center of Chemical Injury, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Lin Zhang
- Center of Emergency & Intensive Care Unit, Medical Center of Chemical Injury, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Jie Shen
- Center of Emergency & Intensive Care Unit, Medical Center of Chemical Injury, Jinshan Hospital, Fudan University, Shanghai 201508, China
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Caluwaerts M, Castanares-Zapatero D, Laterre PF, Hantson P. Prognostic factors of acute mesenteric ischemia in ICU patients. BMC Gastroenterol 2019; 19:80. [PMID: 31146693 PMCID: PMC6543602 DOI: 10.1186/s12876-019-0999-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 05/22/2019] [Indexed: 02/07/2023] Open
Abstract
Background The primary endpoint was to investigate the prognostic factors of acute mesenteric ischemia (AMI) in ICU patients. Methods Retrospective observational, non-interventional, monocentric study of a cohort of 214 ICU patients with a confirmed diagnosis of arterial AMI. Results We collected demographics, mortality, hospital stay, prior medical history, comorbidities, reasons for ICU admission, laboratory investigations, diagnostic procedures, therapy, severity scores. The 30-day mortality rate was 71% for the 214 patients with arterial AMI. The incidence of nonocclusive mesenteric ischemia was particularly high. AMI was a secondary diagnosis in 58% of patients. Half of the population was represented by surgical patients who mostly required an urgent procedure. The mortality rate was not different in the subgroup with aortic surgery. Three factors were associated with an increase or decrease in mortality: the maximal dose of vasopressors (VP) administered to the patient (OR = 1.20; 95%CI = 1.08–1.33; p < 0.001), arterial change in lactate values within the first 24 h of admission (OR = 1.24; 95%CI = 1.05–1.48; p = 0.012) and anticoagulation (OR = 0.19; 95%CI = 0.043–0.84; p = 0.029). Conclusions Fatalities after AMI were related to a high incidence of multi-organ failure. The monitoring of arterial lactate appeared helpful to identify the patients with a poor prognosis.
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Affiliation(s)
- Martin Caluwaerts
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Diego Castanares-Zapatero
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium
| | - Philippe Hantson
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Avenue Hippocrate, 10, 1200, Brussels, Belgium.
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Nakamura F, Yui R, Muratsu A, Onoe A, Nakajima M, Takahashi H, Kishimoto M, Sakuramoto K, Muroya T, Kajino K, Ikegawa H, Kuwagata Y. A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study. Acute Med Surg 2019; 6:365-370. [PMID: 31592320 PMCID: PMC6773662 DOI: 10.1002/ams2.422] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/28/2019] [Indexed: 01/13/2023] Open
Abstract
Aim The purpose of this study was to determine the prognostic factors of non‐occlusive mesenteric ischemia (NOMI) and to examine treatment strategies that could improve its prognosis. Methods We retrospectively identified 30 patients who underwent emergency laparotomy for NOMI in Kansai Medical University Hospital (Hirakata, Japan) from April 2013 to December 2017. We examined prognostic factors related to discharge outcome and also examined the prognostic impact of open abdominal management and second look operation strategy (OSS) by dividing the patients into the non‐OSS group and the OSS group. Results The primary end‐point was a prognostic factor for outcome at discharge of the 30 patients. The outcome at discharge was compared between the survival group and the death group. Multivariate analysis was undertaken on two items from the univariate analysis that showed a significant difference (computed tomography findings of intestinal pneumatosis and acute disseminated intravascular coagulation [DIC] score). As a result, there was a significant difference in the factors of intestinal pneumatosis (odds ratio = 0.054; 95% confidence interval, 0.005–0.607; P = 0.018) and DIC score (odds ratio = 1.892; 95% confidence interval, 1.077–3.323; P = 0.027). The secondary end‐point was the treatment outcome before and after the application of OSS. Operation time was significantly shorter and the amount of bleeding was also significantly less in the OSS group. Conclusion Computed tomography findings of intestinal pneumatosis and the acute disseminated intravascular coagulation score were found to be prognostic factors for survival in patients with NOMI. Aggressive laparotomy to determine the definitive diagnosis is needed and OSS could be useful to improve patient prognosis for survival from NOMI.
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Affiliation(s)
- Fumiko Nakamura
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Rintaro Yui
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Arisa Muratsu
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Atsunori Onoe
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Mari Nakajima
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Hiroki Takahashi
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Masanobu Kishimoto
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Kazuhito Sakuramoto
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Takashi Muroya
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Hitoshi Ikegawa
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine Kansai Medical University Hirakata Osaka Japan
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Nitta N, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Ohgi K, Uesaka K. A case of pancreatic cancer invading the superior mesenteric artery causing extensive intestinal necrosis that was successfully treated by surgery. J Surg Case Rep 2019; 2019:rjz118. [PMID: 31044060 PMCID: PMC6479187 DOI: 10.1093/jscr/rjz118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 11/12/2022] Open
Abstract
Introduction Pancreatic cancer often invades major arteries. However, there are few reports about extensive bowl necrosis caused by superior mesenteric artery (SMA) occlusion associated with pancreatic cancer invasion. Case report A 73-year-old woman who was receiving chemotherapy for locally advanced pancreatic cancer (LAPC) was referred to our hospital for abdominal swelling and vomiting that had persisted for 2 days. Contrast-enhanced computed tomography revealed occlusion of the SMA by pancreatic cancer, which had invaded the whole circumference of the SMA. On emergency laparotomy, a large amount of necrotic and ischemic intestine was resected, preserving approximately 100 cm of the ileum. Gastroileostomy was also performed. She had an uneventful postoperative course. Conclusions Surgical treatment is a good option for acute SMA occlusion due to invasion by LAPC.
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Affiliation(s)
- Nobuhito Nitta
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Grotelüschen R, Bergmann W, Welte MN, Reeh M, Izbicki JR, Bachmann K. What predicts the outcome in patients with intestinal ischemia? A single center experience. J Visc Surg 2019; 156:405-411. [PMID: 30745185 DOI: 10.1016/j.jviscsurg.2019.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is associated with a mortality of 60-80%. Early diagnosis and rapid treatment have a decisive influence on therapy. The aim of this study was to evaluate the prognostic value of AMI markers on mortality, in order to better anticipate the clinical course and to initiate therapeutic steps at an early stage. STUDY DESIGN An analysis from our prospective database of 302 consecutive patients with AMI who were treated surgically in the Department of General Surgery between February 2003 and October 2014 was performed. Uni- and multivariate analysis of risk factors for mortality have been performed in the total cohort and in two subgroups according to their stay in intensive care unit (ICU) at the time of AMI diagnosis. RESULTS Of the 302 patients with AMI, 115 were in ICU at the time of diagnosis. Totally, 203 patients underwent computed tomography scan (CT-scan) of the abdomen for diagnosis and 68% of them showed specific signs of AMI. A total of 63 (21%) embolectomies were performed during the surgical procedure. The post-operative mortality rate was 68% (204 patients). Among survivors, 85 (87%) patients developed a short bowel syndrome in the post-operative course. Multivariate analysis showed a significant association between mortality and preoperative lactate>3mmol/L, C-reactive protein>100mg/L and ICU stay at the time of AMI diagnosis. CONCLUSION Mortality of patients with AMI remains high. Elevated lactate, elevated C-reactive protein and ICU stay are factors associated with increased mortality. Their presence in a patient with suspicion of AMI should trigger a multidisciplinary management in emergency.
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Affiliation(s)
- R Grotelüschen
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - W Bergmann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - M N Welte
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - M Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - J R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - K Bachmann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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Clinical Features and Outcomes of Patients With Acute Mesenteric Ischemia and Concomitant Colon Ischemia: A Retrospective Cohort Study. J Surg Res 2019; 233:231-239. [DOI: 10.1016/j.jss.2018.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 07/16/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022]
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Montagnana M, Danese E, Lippi G. Biochemical markers of acute intestinal ischemia: possibilities and limitations. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:341. [PMID: 30306080 DOI: 10.21037/atm.2018.07.22] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute intestinal ischemia is a relative rare abdominal emergency, associated with considerably high morbidity and mortality rates. Although the conventional diagnostic approach to acute intestinal ischemia entails a preliminary evaluation of signs and symptoms, followed by radiological and laboratory investigations, a definitive diagnosis is can usually be made after laparotomy, which still remains the gold standard diagnostic (and therapeutic) procedure. Several potential laboratory biomarkers have been investigated over the past decades, but none of these seems to reach a suitable diagnostic accuracy for an early and reliable diagnosis of intestinal ischemia. The aim of this narrative review is to provide an overview on traditional laboratory tests for diagnosing acute intestinal ischemia (i.e., complete blood count, D-dimer, blood gas analysis, total lactic acid, C-reactive protein and procalcitonin), and summarize current evidence regarding some emerging and potentially useful biomarkers such as D-lactate, intestinal fatty acid-binding protein (I-FABP), ischemia modified albumin (IMA), α-glutathione S-transferase (α-GST), interleukin-6 (IL-6), citrulline and smooth muscle protein of 22 kDa (SM22). Among the various tests, D-lactate, IMA and I-FABP are perhaps the most promising, since they are characterized by optimal sensitivity and relatively good specificity, early kinetics, and can be measured with assays suited for a rapid diagnosis.
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Affiliation(s)
- Martina Montagnana
- Clinical Biochemistry Section, University Hospital of Verona, Verona, Italy
| | - Elisa Danese
- Clinical Biochemistry Section, University Hospital of Verona, Verona, Italy
| | - Giuseppe Lippi
- Clinical Biochemistry Section, University Hospital of Verona, Verona, Italy
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Abstract
Acute mesenteric ischemia is a surgical emergency commonly caused by embolic or thrombotic occlusion of the superior mesenteric artery. Prompt diagnosis, fluid resuscitation, systemic anticoagulation, and mesenteric revascularization are key tenants to the treatment of this lethal condition. Revascularization can be performed via open thromboembolectomy or surgical bypass, endovascular techniques, or a hybrid approach of the 2. Despite technological advancements, mortalities remain high, and the plan of care and revascularization should be based on the patient's clinical status and available medical center resources.
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Affiliation(s)
- Bryan A Ehlert
- Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, 115 Heart Drive, Mail Stop 651, Greenville, NC 27834, USA.
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Surgical Rescue in Medical Patients: The Role of Acute Care Surgeons as the Surgical Rapid Response Team. Crit Care Clin 2018; 34:209-219. [PMID: 29482901 DOI: 10.1016/j.ccc.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Failure to rescue is death occurring after a complication. Rapid response teams developed as a prompt intervention for patients with early clinical deterioration, generally from medical conditions or complications. Patients with surgical complications or surgical pathology require prompt evaluation and management by surgeons to avoid deterioration; this is surgical rescue. Patients in the medical intensive care unit may develop intra-abdominal pathology that requires expeditious operative intervention. Acute care surgeons should serve as the surgical rapid response team to help assess and manage these complex patients. Collaboration between intensivists and surgeons is essential to rescue patients from complications and surgical disease.
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Tseng J, Loper B, Jain M, Lewis AV, Margulies DR, Alban RF. Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study. Trauma Surg Acute Care Open 2017; 2:e000126. [PMID: 29766117 PMCID: PMC5887781 DOI: 10.1136/tsaco-2017-000126] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/09/2023] Open
Abstract
Background Surgical intervention for ischemic colitis is associated with significant postoperative morbidity and mortality. Predictive factors of adverse outcomes have been reported in the literature, but are based on small sample populations. We sought to identify risk factors for mortality after emergent colectomy for ischemic colitis using a clinical outcomes database. Methods The American College of Surgeons National Surgical Quality Improvement Project database was queried from 2010 to 2015 to identify emergent colectomies performed for ischemic colitis using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Univariate and multivariate logistic regression analysis was used to identify independent risk factors associated with increased risk of mortality. Results A total of 4548 patients undergoing emergent colectomies for ischemic colitis were identified. Overall, 30-day postoperative mortality was 25.3%. On univariate analysis, preoperative risk factors associated with a higher rate of mortality include dyspnea, functional status, ventilator dependency, history of chronic obstructive pulmonary disease, ascites, congestive heart failure exacerbation, hypertension, dialysis dependency, cancer, open wounds, chronic steroids, weight loss >10%, transfusions within 72 hours before surgery, septic shock and duration from hospital admission to surgery. Factors that were significant for mortality on logistic regression analysis include elderly age, poor functional status, multiple comorbidities, septic shock, blood transfusion, acute renal failure and the duration of time from hospital admission to surgery. Conclusions Postoperative morbidity and mortality rates for ischemic colitis remain significantly high. Identification of risk factors may help patient selection for surgical interventions, and make informed decisions with patients and family members. Although it is certainly challenging, early diagnosis and prompt surgical intervention for patients with ischemic colitis may improve outcomes. Study type and level of evidence Therapeutic/care management, level II
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brandi Loper
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Monica Jain
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Azaria V Lewis
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rodrigo F Alban
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Hu WS, Lin CL. Stroke prediction with CHA 2DS 2-VASc score in patients with mesenteric ischemia without atrial fibrillation-insights from a nationwide cohort. J Clin Neurosci 2017; 45:193-198. [PMID: 28684149 DOI: 10.1016/j.jocn.2017.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/09/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The current study sought to evaluate the accuracy of CHA2DS2-VASc score for ischemic stroke prediction in patients with mesenteric ischemia without atrial fibrillation (AF). METHODS The study participants included patients aged ≥18years with a new diagnosis of mesenteric ischemia during hospitalization between January 1, 2000 and December 31, 2011. Individuals with atrial fibrillation (AF) or atrial flutter during the study period were excluded. The study participants were followed up until the ischemic stroke appeared or they were censored due to withdrawal from this program, mortality, or the end of the study period, whichever came first. Cox proportional hazards regression models were applied for ischemic stroke risk stratification in the study participants by CHA2DS2-VASc score. The c-statistic based on the receiver operating characteristic (ROC) analysis was applied to investigate the accuracy of CHA2DS2-VASc score for ischemic stroke risk discrimination. RESULTS A total of 24039 study participants were enrolled. Ischemic stroke incidence increased from 1.54% in CHA2DS2-VASc score of 0 to 9.23% in CHA2DS2-VASc score of 6 or more. Moreover, the Kaplan-Meier curve with a log rank test demonstrated that patients with a higher CHA2DS2-VASc score were associated with an increased cumulative incidence rate of ischemic stroke during the follow-up period (p<0.001). The discriminatory performance of the CHA2DS2-VASc score resulted in C-statistics of 0.65(95% CI=0.63-0.66) for predicting ischemic stroke risk among patients with mesenteric ischemia without AF. CONCLUSIONS A higher CHA2DS2-VASc score is demonstrated to be associated with an increased risk of ischemic stroke among patients with mesenteric ischemia without comorbid AF.
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Affiliation(s)
- Wei-Syun Hu
- School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan; Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan.
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung 40447, Taiwan
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Kim HK, Hwang D, Park S, Huh S, Lee JM, Yun WS, Kim YW. Effect of Clinical Suspicion by Referral Physician and Early Outcomes in Patients with Acute Superior Mesenteric Artery Embolism. Vasc Specialist Int 2017; 33:99-107. [PMID: 28955699 PMCID: PMC5614378 DOI: 10.5758/vsi.2017.33.3.99] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate the pattern of referral of patients with superior mesenteric artery embolism (SMAE) and its effect on outcomes, and to evaluate the risk factors for bowel infarction. MATERIALS AND METHODS This retrospective study included 66 consecutive patients diagnosed with acute SMAE between January 2001 and June 2016. Appropriate diagnosis by the referring physician was defined if the referral letter indicated that acute mesenteric ischemia was suspected or had been diagnosed at the referral center. Surgical delay was defined as the interval between symptom onset and surgery for definitive treatment. RESULTS Among 54 patients transferred from other centers, 26 patients (48.1%) were diagnosed appropriately by the referring physician. The rate of appropriate diagnosis was differed significantly by the use of computed tomography (CT) scan at referral center (25/35 with CT and 1/19 without CT, P=0.00). The surgical delay was significantly longer in patients without appropriate diagnosis compared with the patients with appropriate diagnosis (53.5±52.3 hours vs. 28.8±23.6 hours, P=0.04). Initially, 56 patients received surgical treatment with 31 underwent bowel resection due to infarction, 6 received conservative treatment, and the remaining 4 patients refused any treatment. The surgical delay, abdominal distension, tenderness, rebound tenderness, and level of C-reactive protein were associated with bowel infarction at initial operation. Overall in-hospital mortality was 32%. CONCLUSION A high index of suspicion with appropriate diagnostic modality, such as CT scan is crucial in patients with SMAE for reducing surgical delay as a risk factor of bowel infarction.
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Affiliation(s)
- Hyung-Kee Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Deokbi Hwang
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sujin Park
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Huh
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jong-Min Lee
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Woo-Sung Yun
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Bala M, Kashuk J, Moore EE, Kluger Y, Biffl W, Gomes CA, Ben-Ishay O, Rubinstein C, Balogh ZJ, Civil I, Coccolini F, Leppaniemi A, Peitzman A, Ansaloni L, Sugrue M, Sartelli M, Di Saverio S, Fraga GP, Catena F. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2017; 12:38. [PMID: 28794797 PMCID: PMC5545843 DOI: 10.1186/s13017-017-0150-5] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process. Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.
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Affiliation(s)
- Miklosh Bala
- Acute Care Surgery and Trauma Unit, General Surgery Department, Hadassah - Hebrew University Medical Center, Kiriat Hadassah, POB 12000, 91120 Jerusalem, Israel
| | - Jeffry Kashuk
- Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, USA
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Department of Surgery, Queens Medical Center, Honolulu, Hi USA
| | - Carlos Augusto Gomes
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Chen Rubinstein
- Department of Vascular Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Ian Civil
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | | | | | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinica, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fausto Catena
- Emergency Department, Maggiore University Hospital, Parma, Italy
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46
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Direct peritoneal resuscitation improves mesenteric perfusion by nitric oxide dependent pathways. J Surg Res 2017; 213:274-280. [DOI: 10.1016/j.jss.2017.02.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 02/18/2017] [Accepted: 02/24/2017] [Indexed: 12/30/2022]
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Yıldırım D, Hut A, Tatar C, Dönmez T, Akıncı M, Toptaş M. Prognostic factors in patients with acute mesenteric ischemia. Turk J Surg 2017; 33:104-109. [PMID: 28740960 PMCID: PMC5508232 DOI: 10.5152/ucd.2016.3534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 04/26/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Acute mesenteric ischemia, one of the causes of acute abdominal pain due to occlusion of the superior mesenteric artery, has a fatal course as a result of intestinal necrosis. There is no specific laboratory test to diagnose acute mesenteric ischemia. The basis of treatment in cases of acute mesenteric ischemia is composed of early diagnosis, resection of intestinal sections with infarction, regulation of intestinal blood flow, second look laparotomy when required, and intensive care support. The aim of this study is to investigate the factors affecting mortality in patients treated and followed-up with a diagnosis of acute mesenteric ischemia. MATERIAL AND METHODS Forty-six patients treated and followed-up with a diagnosis of acute mesenteric ischemia between January 1st, 2008 and December 31st, 2014 at the General Surgery Clinic of our hospitalwere retrospectively evaluated. The patients were grouped as survivor (Group 1) and dead (Group 2). Age, gender, accompanying disorders, clinical, laboratory and radiologic findings, duration until laparotomy, evaluation according to the Mannheim Peritonitis Index postoperative complications, surgical treatment applied, and type of ischemia and outcome following surgery were recorded. RESULTS A total of 46 patients composed of 22 males and 24 females with a mean age of 67.5±17.9 and with a diagnosis of mesenteric ischemia were included in the study. Twenty-seven patients died (58.7%) while 19 survived (41.3%). The mean MPI score was 16.8±4.7 and 25.0±6 in Group 1 and Group 2, respectively, and the difference between the two groups was statistically significant (p<0,001). Fourteen of the 16 (51.9%) patients who had a Mannheim Peritonitis Index score of 26 or higher died while two of them survived (10.5%). Thirteen out of the 30 (48.1%) patients with a Mannheim Peritonitis Index score of 25 or lower died while 17 (89.5%) patients survived. The increased MPI score was significantly correlated withmortality (p=0.004). CONCLUSION Suspicion of disease and early use of imaging in addition to clinical and laboratory evaluations are essential in order to decrease mortality rates in acute mesenteric ischemia. Prevention of complications with critical intensive care during the postoperative period aids in decreasingthe mortality rate. In addition, using the Mannheim Peritonitis Index can be helpful.
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Affiliation(s)
- Doğan Yıldırım
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Adnan Hut
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Cihad Tatar
- Clinic of General Surgery, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Turgut Dönmez
- Clinic of General Surgery, Lütfiye Nuri Burat State Hospital, İstanbul, Turkey
| | - Muzaffer Akıncı
- Clinic of General Surgery, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Toptaş
- Clinic of Anesthesiology and Reanimation, Haseki Training and Research Hospital, İstanbul, Turkey
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Jensen AR, Drucker NA, Khaneki S, Ferkowicz MJ, Markel TA. Hydrogen sulfide improves intestinal recovery following ischemia by endothelial nitric oxide-dependent mechanisms. Am J Physiol Gastrointest Liver Physiol 2017; 312:G450-G456. [PMID: 28280145 PMCID: PMC5451562 DOI: 10.1152/ajpgi.00444.2016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 01/31/2023]
Abstract
Hydrogen sulfide (H2S) is an endogenous gasotransmitter that has vasodilatory properties. It may be a novel therapy for intestinal ischemia-reperfusion (I/R) injury. We hypothesized that 1) H2S would improve postischemic survival, mesenteric perfusion, mucosal injury, and inflammation compared with vehicle and 2) the benefits of H2S would be mediated through endothelial nitric oxide. C57BL/6J wild-type and endothelial nitric oxide synthase knockout (eNOS KO) mice were anesthetized, and a midline laparotomy was performed. Intestines were eviscerated, the small bowel mesenteric root identified, and baseline intestinal perfusion was determined using laser Doppler. Intestinal ischemia was established by temporarily occluding the superior mesenteric artery. Following ischemia, the clamp was removed, and the intestines were allowed to recover. Either sodium hydrosulfide (2 nmol/kg or 2 µmol/kg NaHS) in PBS vehicle or vehicle only was injected into the peritoneum. Animals were allowed to recover and were assessed for mesenteric perfusion, mucosal injury, and intestinal cytokines. P values < 0.05 were significant. H2S improved mesenteric perfusion and mucosal injury scores following I/R injury. However, in the setting of eNOS ablation, there was no improvement in these parameters with H2S therapy. Application of H2S also resulted in lower levels of intestinal cytokine production following I/R. Intraperitoneal H2S therapy can improve mesenteric perfusion, intestinal mucosal injury, and intestinal inflammation following I/R. The benefits of H2S appear to be mediated through endothelial nitric oxide-dependent pathways.NEW & NOTEWORTHY H2S is a gaseous mediator that acts as an anti-inflammatory agent contributing to gastrointestinal mucosal defense. It promotes vascular dilation, mucosal repair, and resolution of inflammation following intestinal ischemia and may be exploited as a novel therapeutic agent. It is unclear whether H2S works through nitric oxide-dependent pathways in the intestine. We appreciate that H2S was able to improve postischemic recovery of mesenteric perfusion, mucosal integrity, and inflammation. The beneficial effects of H2S appear to be mediated through endothelial nitric oxide-dependent pathways.
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Affiliation(s)
- Amanda R. Jensen
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,3Indiana University School of Medicine, Indianapolis, Indiana
| | - Natalie A. Drucker
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,3Indiana University School of Medicine, Indianapolis, Indiana
| | - Sina Khaneki
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana;
| | - Michael J. Ferkowicz
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,3Indiana University School of Medicine, Indianapolis, Indiana
| | - Troy A. Markel
- 1Section of Pediatric Surgery, Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana; ,2Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana; and ,3Indiana University School of Medicine, Indianapolis, Indiana
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49
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Forbrig R, Renner P, Kasprzak P, Dahlke MH, Müller-Wille R, Stroszczynski C, Heiss P. Outcome of primary percutaneous stent-revascularization in patients with atherosclerotic acute mesenteric ischemia. Acta Radiol 2017; 58:311-315. [PMID: 27178034 DOI: 10.1177/0284185116647212] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Patients with acute mesenteric ischemia (AMI) often exhibit severe co-morbidities and significant surgical risks, leading to high perioperative morbidity. Purpose To investigate the feasibility of primary percutaneous stent-revascularization (PPSR) in atherosclerotic AMI and its impact on patients' outcome. Material and Methods Retrospective analysis of 19 consecutive patients (7 women, 12 men; median age, 69 years) with AMI caused by atherosclerotic, non-embolic stenoses/occlusions of the splanchnic arteries and PPSR. Alternative minimally invasive techniques were excluded. Clinical characteristics including the Charlson Comorbidity Index adjusted by age (CCIa) and symptom duration, technical and clinical success of PPSR, clinical course, 30-day mortality, and follow-up were evaluated and compared to literature data for surgical approaches. Technical success was defined as residual stenosis of <30% in diameter. Clinical success was defined as resolution of symptoms of AMI and/or normalization of serum lactate after sole PPSR. Results The majority of patients presented with severe co-morbidities (CCIa >4 in 17 of 19 patients, 89%). Median symptom duration was 50 h. Technical and clinical success rates of PPSR were 95% (21 of 22 arteries) and 53% (10 of 19 patients). Seven patients underwent subsequent laparotomy with bowel resection in four cases. Thirty-day mortality was 42% (8 of 19 patients). Conclusion In our study population of patients with atherosclerotic AMI, severe co-morbidities, prolonged acute symptoms, and significant perioperative risks PPSR of splanchnic stenoses were technically feasible and the clinical outcome was acceptable.
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Affiliation(s)
- Robert Forbrig
- Department of Neuroradiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | - Philipp Renner
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Piotr Kasprzak
- Department of Vascular Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Marc-H Dahlke
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - René Müller-Wille
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
| | | | - Peter Heiss
- Department of Radiology, University Medical Center Regensburg, Regensburg, Germany
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CHA 2DS 2-VASc score in the prediction of ischemic bowel disease among patients with atrial fibrillation: Insights from a nationwide cohort. Int J Cardiol 2017; 235:56-60. [PMID: 28262350 DOI: 10.1016/j.ijcard.2017.02.097] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 01/05/2017] [Accepted: 02/20/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE This study aimed to evaluate the predictive role of CHA2DS2-VASc score specifically for the development of ischemic bowel disease (IBD) among atrial fibrillation (AF) patients. METHODS Using a nationwide dataset, an AF cohort was established. The study participants were followed up from the index date until they withdrew from the health insurance system, the occurrence of IBD or until the end of 2011. The hazard ratios (HRs) and 95% confidence intervals (CIs) were examined by Cox models to present the subsequent risk of IBD among AF patients by CHA2DS2-VASc score. The area under the receiver operating characteristic (ROC) curve was used to assess the predictive power of CHA2DS2-VASc score for IBD development among AF patients. RESULTS The cumulative incidence of IBD was higher for AF patients with a CHA2DS2-VASc score≥2 than those with a CHA2DS2-VASc score<2 by 2.30% (p<0.001) at the end of follow-up. After adjustment for hyperlipidemia, chronic obstructive pulmonary disease, and chronic kidney disease, the AF patients with a CHA2DS2-VASc score≥2 had a 3.35 times higher risk for IBD development compared to those with a CHA2DS2-VASc score<2 [adjusted HR (aHR)=3.35, 95% CI=2.71-4.13]. Among AF patients, the C-statistic of the CHA2DS2-VASc score as a predictor of IBD was 0.56 (95% CI=0.55-0.57). CONCLUSIONS In conclusion, the study is the first to investigate the predictive role of CHA2DS2-VASc score specifically for IBD development among AF patients. However, the predictive power was relatively low; further studies are necessary to confirm our findings.
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